Provider Demographics
NPI:1629055827
Name:WASSER, MARVIN S (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:S
Last Name:WASSER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 EDEN CREST DR
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-8104
Mailing Address - Country:US
Mailing Address - Phone:401-944-5798
Mailing Address - Fax:
Practice Address - Street 1:496 PONTIAC AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-3520
Practice Address - Country:US
Practice Address - Phone:401-461-2150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI5457208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIC 89710Medicaid